1. Purpose and scope
Introduction
Imaging of children is usually required when other identified injuries (for example, bruising) are unexplained. Due to the nature of some fractures, they are not always visible on early presentation. A primary radiographic skeletal survey is undertaken on presentation.
It is recognised that subsequent images, after a set time interval, may help to reveal fractures not seen on the primary survey.
This paediatric group is normally limited to children under two years old – but it may include older children.
Definitions
Traditional radiographic skeletal survey – imaging of specific areas of a child’s body using X-rays.
Background guidance
The Royal College of Radiologists. The radiological investigation of suspected physical abuse in children. London: The Royal College of Radiologists, 2017.
Key duties
Consultant paediatric radiologists, or other consultant radiologists recognised to undertake the role of reporting images for suspected abuse, should ensure that the report of the preliminary findings includes requirements for follow-up imaging and the time interval.
This interval should normally be set in the ‘standard operating procedure for identifying unexplained injuries in paediatrics.’ Staff performing the primary survey will make those with parental responsibility aware of this procedure.
Consultant paediatricians and other medical staff involved should also be aware of this procedure so that when discussing the findings of the primary survey they are able to inform those with parental responsibility that the final report will not be issued until the follow-up imaging has been performed.
Monitoring and assurance
A robust system should be put in place to ensure that a child is brought in for this follow-up imaging, and who should act if the child does not attend. An appointment should be provided during normal working hours.
Initial discussion involving all parties should decide which department should monitor this.
It makes sense for imaging services to do this via their booking system. The appointment should be put on the system at the time of the primary survey and those with parental responsibility provided with a written appointment sheet. It is prudent to inform the consultant radiologist and paediatric radiographers.
The imaging service should have in place a policy for those patients that do not attend for bookings. An alert should be attached to this booking so that non-attendance is immediately flagged.
If a child is not brought in for the appointment then clerical staff should bring this fact to the attention of both the reporter of the primary survey and the paediatric radiographers.
Clerical staff should be trained to understand the importance of this communication. It is good practice for the lead paediatric radiographer to be involved in this chain, and to act as a second line of monitoring any shortfalls.
On being alerted to the missed appointment an escalation plan should be implemented.
This should detail any process to determine why the child was not brought in. A clear chain of responsibility should be described. This should involve the assistance of the safeguarding children team, children’s social carer and the child’s consultant paediatrician.
The reason for non-attendance should be ascertained and the carers should then be advised to bring the child in for further imaging within a suitable time frame (follow-up imaging is still of value up to 28 days after the initial survey), within normal working hours.
Refusal to attend or inability to make contact must be discussed with the referring paediatric consultant in case legal action is required. If this is the outcome, then the responsibility now lies with the original paediatric consultant and the safeguarding team.
Responsibility for monitoring these results lies with the imaging department, and ultimately with the consultant radiologist reporting the primary survey. A robust working relationship between all parties should be maintained with clear and open communication channels.
There may be occasions when follow-up imaging is performed at another centre. Where this is the case then all parties involved in facilitating the original survey should be aware. It is also important that the other centre knows what specific images are to be performed and who is going to report them. This will involve radiologists and radiographers at both centres.
A record should be kept of skeletal surveys performed by the imaging department. The information should be audited to:
§ Aid in making improvements to the system, for example, in relation to:
– Staff training – Staff availability – Timescales – Communication – Image quality
§ Monitor activity in this specific paediatric area
§ Compare with national data
§ Demonstrate any trends.
2. Procedure to follow
This section should be completed by individual organisations Main step 1
Summary of step
Main step 2 Summary of step
Wherever possible, or relevant, support this narrative with a range of:
§ Process and decision flow charts, which reflect the key duties
§ Functions and responsibilities tables
§ Monitoring and quality assurance arrangements.
3. Document ratification process
This section should be completed by individual organisations.
4. Reference material
The Royal College of Radiologists. The radiological investigation of suspected physical abuse in children. London: The Royal College of Radiologists, 2017.
Plus any individual organisation guidelines.
Appendix 1
Appendices should be specifically referred to in the body of the procedural note and included within the contents page.
Required documentation
Include copies of each form that is needed to be completed as part of the procedure described. If this is not practical or appropriate, then clearly indicate where the reader may locate the relevant forms. Aim to standardise forms used across the organisation. Where this is not possible, aim for partial standardisation, with specific additional sections to reflect differences across specialties and functions.
Electronic processes and records
Include brief descriptions, supplemented with (for example) screen prints, key function flowcharts, system menus and so on, with links to electronic guidance for each of the key software packages used as part of the procedure.
Specialised processes
Include further detailed steps for processes, where it makes sense to include within the main procedural document, that is, where the majority of the procedure is the same as the standard approach, but with specific and significant differences at certain stages of the procedure.